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Health Professionals and Hospital Administrators in Organ Procurement: Attitudes, Reservations, and Their Resolutions JEFFREY PROTTAS, PHD,
AND
Abstract: The responses of hospital administrators, directors of nursing, intensive care unit nurses, and neurosurgeons are reported to a range of inquiries designed to measure their commitment to organ procurement and thereby identify impediments limiting their cooperation with organ procurement efforts. Descriptive and multivariate statistical techniques are used to analyze data collected from each group. We find general approval for organ procurement
Introduction In the United States, nearly I I,000 people are on queues awaiting an organ transplant. I,2 The number of organ donors has also increased consistently over the years, but at nothing like the same rate. Each year, the number of transplants done and the length of the waiting lists increase. Historically, numerous surveys have shown that the American public is committed to a voluntaristic system of organ donation, and surveys of organ procurement agencies confirm that about three-fourths of those asked for donation give permission. -6 If the public is so willing to donate, why are there so few actual donors? Will it be possible for the voluntary system to supply an adequate number of solid organs for those who need them? Answers to these questions cannot be found only among the giving public; they must be sought earlier in the process of organ donation. Granting permission is one of the last steps in a successful organ procurement. The earlier and, in practice, more problematic stages, involve the medical professionals caring for terminal patients. They must identify donors to an appropriate agency in a timely way, allow organ procurement agencies access to the donors and their families, and perform certain clinical and interpersonal tasks that are, in practice, a precondition to gaining familial permission. In short, they control access to potential donors. In this article we report the responses of four key professional groups to a range of inquiries designed to measure their commitment to organ procurement and thereby identify impediments limiting their cooperation with organ procurement efforts.
Methods Representative random samples of neurosurgeons, intensive care unit nurses, directors of nursing, and hospital administrators were surveyed by mail as to their attitudes and opinions about organ donation. Sixty-eight per cent of a sample of 362 neurosurgeons (246 respondents), randomly selected from the membership list of the American Association of Neurological Surgeons, responded to a 50-item questionnaire about organ donation. In separate surveys, hospital administrators, directors of nursing, and four intenFrom Brandeis University, Bigel Institute for Health Policy. Address
repnint requests to Jeffrey Prottas, PhD, Acting Director, Bigel Institute for
Health Policy, Heller Graduate School, Brandeis University, 415 South Street, Waltham, MA 02254-3900. Ms. Batten is a Research Associate at the Institute. This paper, submitted to the Journal June 18, 1987, was revised and accepted for publication December 22, 1987. Editor's Note: See also related editorial p 621 this issue. © 1988 American Journal of Public Health 009-)0036/88$1.50
642
HELEN LEVINE BATTEN, MA but serious hesitation about dealing with donor families, particularly among physicians. Physician support for donation, moreover, is the strongest predictor ofother professionals, attitudes toward donation.
Neurosurgeons and intensive care unit nurses who believe organ procurement is a professional responsibility have the fewest reservations about facilitating organ donation. (Am J Public Health 1988;
78:642-645.)
sive care unit nurses from 344 hospitals were surveyed. The hospitals, randomly selected by the American Hospital Association from their member institutions, were acute care hospitals of more than 100 beds and without a transplant program of their own. These surveys (of about 90 questions each) yielded a 65 per cent response rate from each group (administrators, n=222; directors of nursing, n=227; and intensive care unit nurses, n=878). Finally, a representative sample of the public (n=750), selected through the Waksburg random-digit dialing method, were also surveyed by telephone about their attitudes towards organ donation. There are few important differences between survey respondents and their peers based on national data. Neurosurgeons and hospital administrators who responded tended to be slightly older than nonrespondents.7,* On the other hand, responding nurses are somewhat younger than their peers.7 Proportionately more women hospital administrators and directors of nursing responded to the survey than population statistics would predict.7 Perhaps, most significantly, responding nurses and hospital administrators were more likely to have graduate degrees than their peers.7'8
Differences among hospital administrators and the two nurse groups may be accounted for by the fact that the samples were drawn excluding the smallest hospitals (with less than 100 beds). Results
Responses presented here represent the percentage of those who agreed with the statements in the vertical axes of Tables I through 5. Except for the last three statements in Table I (where a yes or no response was permitted), the remaining questions in Tables 1 through 5 were scaled from "strongly agree" to "strongly disagree." Those who strongly agreed and those who agreed are combined and presented here as "agreed." Table columns are blank if a question was not asked of a sample group. Approval of Organ Donation Virtually all the professionals support organ donation, would donate their own organs and would consider giving permission for procurement of a relative's organs (Table 1). Professionals are generally more supportive than the general public. Nurses are more likely to have discussed donation with their families than is the general public or neurosurgeons. * American Medical Association, Data Resources Division, telephone conversation September 9, 1987.
AJPH June 1988, Vol. 78 No. 6
HEALTH PROFESSIONALS IN ORGAN PROCUREMENT TABLE 1-Pw Cent of Respondents' Peronal Support for Organ Donation
Hospital Administrators
Directors of Nursing
ICU Nurses
Neurosurgeons
Public
(N = 222)
(N = 227)
(N = 878)
(N = 246)
(N = 750)
91
93
93
91
90
-
96
94
91
72
-
68
71
52
46
-
96
95
94
53
Professionals' Support Personally strongly approve of organ donation Would consider donating own organs Have discussed my feelings about organ donation with my family Would consider giving permission to have a family member's organs donated
Perceptions of Support for Organ Donation
Each group considers its support to be greater than that of any other group (Table 2). The most striking difference is in the self-perception of the neurosurgeons and the way physicians are perceived by the nurses. It should be noted that neurosurgeons were asked to respond in terms of their own colleagues, while nurses and administrators were asked to respond in terms of physicians in general. Nevertheless, the difference in question phraseology may not be as great as it appears. Neurosurgeons are necessarily directly involved in the donation process and it is with them that ICU nurses must work on these matters. Earlier qualitative research by us indicates that, when nurses talk about doctors and organ procurement, they often refer to neurosurgeons. Clinical Reservations Concerning Organ Procurement As Table 3 illustrates, neurosurgeons have few scientific reservations about brain-death, but nurses are far less clear on this point. However, almost half of neurosurgeons believe that their colleagues have trouble with making brain-death declarations. Regarding familiarity with the medical criteria for organ donation, the same pattern reappears. Even more strikingly, each non-physician group believes that nurses are better acquainted with donor criteria than are physicians. Similar percentages of ICU nurses and neurosurgeons TABLE 2-Per Cent of Health Protesionals' Agreement about Own and Other Groups' Support for Organ Donation Directors of Hospital Administrators Nursing
(N Physicians strongly support concept of organ donation* Nurses strongly support concept of organ donation Hospital administrators strongly support concept of organ
donation
=
222) (N
=
ICU Nurses Neurosurgeons
227) (N
=
878)
(N
=
246)
41
27
29
71
68
70
83
-
71
59
60
Neurosurgeons asked about support among own colleagues. Other respondents asked about support by physicians in general.
AJPH June 1988, Vol. 78 No. 6
are concerned about conflicting protocols in treating patients who may become organ donors. However, ICU nurses are nearly one-and-a-half times more likely than neurosurgeons to consider that organ procurement falls within their definition of professional responsibility. Reluctance to Contact Families of Donors
Table 4 supports the accuracy of a perception that medical/health professionals often hesitate to cooperate because they fear contacting the families of donors. Eighty-one TABLE 3-Per Cont of Health Profeslonals' Agreement with Statements about Clinical Issues Directors Hospital of ICU Administrators Nursing Nurses Neurosurgeons (N = 222) (N = 227) (N = 878)
Medical and clinical guidelines for deciding if a patient is brain-dead are well-established Physicians don't like to become involved in making brain-death decisions Physicians are aware of criteria which make a terminally ill patient a possible candidate for organ donation Nurses are aware of criteria which make a terminally ill patient a possible candidate for organ donation Medical protocols for treating a patient who may become an organ donor often oonflict with procedures for protecting organs which may be transplanted Clinicians feel organ procurement activities are a professional responsibility
(N = 246)
69
56
53
88
76
87
81
44
66
55
49
96
72
68
69
-
48
58
59
-
-
75
51
643
PROTTAS AND BATTEN TABLE 4-Per Cent of Medical Professionals Concerned about Families of Donors
Hospital Administrators
Directors of
Nursing
ICU Nurses
Neurosurgeons
(N = 222)
(N = 227)
(N = 878)
(N = 246)
82
86
79
66
-
-
-
48
80
91
89
68
Organ donation helps families grieve Donor families would see somewhat of a conflict for neurosurgeons to request organ donation Physicians are somewhat reluctant to approach families about organ donation
per cent of the public believes that organ donation helps a family deal with its grief, but only 66 per cent of neurosurgeons believe this. Almost half of neurosurgeons believe that families will see a conflict of interest in their playing a role in organ donation, and two-thirds report that their colleagues are at least somewhat reluctant to approach families. Other health professionals believe that physicians are more reluctant than their colleagues believe them to be. The "Costs" of Procurement
Three other "costs" affect professional involvement in organ procurement: fear of legal liability, concern about the amount of time involved, and the emotional demands of involvement. From the point of view of hospital administrators, legal exposure is not an important problem. Physicians, on the other hand, are concerned. Although the law provides physicians with exceptional protections in the area of organ procurement,9 more than half of neurosurgeons report that their colleagues often express concern about the legal implications of organ procurement for them personally (Table 5). Almost half of neurosurgeons hesitate to involve them-
selves because of the amount of time they may have to commit. There is general agreement among those surveyed that organ procurement places heavy emotional demands on all medical/health professionals involved. Given the nature of the activity, any other finding would have been surprising. The professionals surveyed were heterogeneous in their opinions and judgments. To examine associations affecting favorable attitudes, we performed multivariate analyses (available on request to authors) with age, teaching hospital affiliation, hospital size, experience with organ donation, attitudes towards physician support, and professional responsibility in organ procurement as independent variables, and positive attitudes as the dependent variable. Perceptions of peer support and feelings of professional responsibility stand out among neurosurgeons who are positive about donation. Among nurses, experience with donation and perceptions of physician support are associated with favorable attitudes. Perceptions of physician support was most prominent among hospital administrators favorable to donation.
TABLE 5-Subjective Costs of Involvement Hospital Administrators
(N Physicians often express concem about their legal liability in the organ procurement process Hospital administrators often express concern about the hospital's legal liability in the organ procurement process Physicians are somewhat likely to hesitate to become involved in an organ donation because of the time involved Nurses find organ procurement activities somewhat
time-consuming Hospital administrators find organ procurement activities somewhat time-consuming Physicians find organ procurement emotionally
demanding Nurses find organ procurement somewhat emotionally demanding
644
=
222)
Directors of Nursing (N
=
227)
ICU Nurses (N
=
878)
25
40
30
19
15
-
-
-
-
61
77
77
37
35
57
77
87
81
82
86
84
Neurosurgeons (N = 246)
51
46
74
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HEALTH PROFESSIONALS IN ORGAN PROCUREMENT
Discussion
Medical/health professionals are the most critical link in the organ procurement process. It is they who control access to potential donors, first identify suitable candidates, and must take responsibility for declaring death and informing the family. Requesting organ donation is a task performed without compensation and at some emotional and time costs to themselves. Moreover, organ procurement tasks differ in kind from those medical professionals are trained for and dedicated to. An intensive care unit (where many potential donors die) is dedicated to saving lives in desperate danger; organ donors are their failures. Despite all this, we have found much willingness to cooperate among all the professionals surveyed. It is clear from these findings that increasing cooperation from medical professionals does not require extensive reeducation or the application of new and complex incentives. Rather it requires a sensitive appreciation of their needs and concerns. Medical issues do not predominate; the medical profession has incorporated into its technological repertoire all those steps needed for organ donation. Social and interpersonal issues are central. It is, by and large, dealing with donor families that daunts medical professionals. This is particularly true of physicians. In turn, our data show that all other professionals are influenced by the stance of doctors. This is not to say that the other groups are unimportant. Education efforts in organ procurement have traditionally been aimed at nurses and the extraordinarily high levels of support found among them implies considerable success. Nevertheless doctors remain critical. Moreover they are
the weakest link in the chain and so the one most in need of strengthening. Our data on neurosurgeons shows that they take their cues regarding organ procurement from their professional peers. As a profession they perceive that they have resolved the major medical issues but the profession has not, at least for many neurosurgeons, provided clear guidance on other matters. In particular, it has not communicated that active assistance in organ procurement is a positive professional duty. ACKNOWLEDGMENTS
This research sponsored by the Health Care Financing Administration, US Department of Health and Human Services.
REFERENCES
1. American Council on Transplantation: US Transplant Statistics, 1986. 2. Ruth RJ: Wyszewianski L, Campbell DA: The future of kidney transplantation: The effects of improvements in survival rate on the shortage of donated kidneys. Med Care 1987; 25:3, 238-249. 3. Gallup Poll: Attitudes and Opinions of the American Public Toward Kidney Donations. Princeton, NJ: Gallup Organization, 1983. 4. Gallup Poll: The US Public's Attitudes toward Organ Transplants/Organ Donation. Princeton, NJ: Gallup Organization, 1983. 5. Prottas J, Batten HL: Attitudes and Incentives in Organ Procurement. Baltimore, MD: Report to the Health Care Financing Administration, 1986. 6. Prottas J: Encouraging altruism: Public attitudes and the marketing oforgan donation. Milbank Mem Fund 1983; 61(2):278-306. 7. Collins L: Executive salaries to rise 6.1 percent in '86. Hospitals, 1985; 59:106. 8. Aiken LH, (ed): Nursing in the 1980s: Crises, Opportunities, Challenges. American Academy of Nursing. Philadelphia, J.B. Lippincott Company, 1982; 101-119, 475-494. 9. Prottas J: The rules for asking and answering: The role of law in organ donation. University of Detroit Law Review, November 1985; 63:183-193.
NCHS Data Users Conference Scheduled for July 1988 The National Center for Health Statistics (NCHS) will hold a data users conference, July 27-29, in Bethesda, Maryland. There is no registration fee for the conference and it is open to all current and potential users of NCHS public use data files. The conference program will include plenary sessions on policy, future directions in data collection and release, and issues related to analysis and use. Workshops will focus on the data files from specific surveys, the developments in software, or new programs in data access. This conference offers the opportunity for data users to meet with NCHS staff and with others who have used data files to exchange information, seek technical assistance and share experiences. The National Center for Health Statistics is the United States government's principal vital and health statistics agency. NCHS provides data on a wide range of health topics including patterns of illness and disability, supply and use of health services, and vital statistics. For more information about the conference and to receive registration information, write to: National Center for Health Statistics, Scientific and Technical Information Branch, 3700 East-West Highway, Room 1-57, Hyattsville, MD 20782; or call Debora Freeman at (301) 436-8500.
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